Archive for the ‘Medical Issues’ Category

CoVid 19 Quick Takes

Friday, April 3rd, 2020

 

Quote of the day: “To put it bluntly, the U.S. economy went from full speed to full stop — and millions of workers were not wearing seat belts.” – Josh Lipsky, director of global business and economics policy at the Atlantic Council, a nonpartisan think tank.

 

Keeping up with all things CoVid 19 is like swimming through Semolina. It takes a lot of fortitude and stamina. But here goes, anyway.

The states versus the nation

Examining the national response to CoVid 19….no, wait, we don’t have a national response. We have close to 60 responses, one for each of the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands and the other US territories. If you don’t think they’re all on their own, just ask Andrew Cuomo. He said yesterday that none of the governors were currently screaming for states rights. They all want help, they all want national leadership, and they want it yesterday, maybe last week. Look at Ron DeSantis, Governor of Florida. For weeks, under withering criticism and through the debacle of Spring Break on the beaches, he refused to issue a Stay At Home order. Said the state didn’t need it. His excuse? The White House hadn’t told him to do it. But yesterday it did, so he did. Well, actually, the White House “recommended” it. DeSantis made a point of saying he “cleared it with the President.”

Contrast DeSantis’s actions with those of Mario Cuomo, Jay Inslee, Gavin Newsom, JB Pritzker, Gretchen Whitmer, Janet Mills, Charley Baker, and Mike DeWine. They’ve all been on their own, but they’ve been decisively responsible, and their constituents will one day thank them.

Every governor is reacting, and reacting is the right word, differently. It’s like watching an Athenian Trireme in the Mediterranean with all 170 oarsmen rowing at different speeds.

Don’t believe me? Let’s look at Stay At Home orders. Here’s a New York Times map showing state Stay At Home orders from 30 March, four days ago:

And here’s the same map as of yesterday, four days later:

The nation’s Governors are all having to act like European Prime Ministers, many of whom have issued travel restrictions and sealed borders. A week ago, Rhode Island’s Governor Gina Raimondo began letting New Yorkers into her state only if they would self-quarantine for 14 days, and she had the National Guard at the border to enforce the order.

All Governors would like their constituents to view them as Horatius At The Bridge, but Covid 19 is likely not the particular bridge they would have in mind. They need national leadership, not national cheerleading. Absent that, they’ve been forced to step into the void, some, like DeSantis, very reluctantly.

Trouble coming for the southeast

Vann R, Newkirk, II, has a terrific piece in this week’s The Atlantic looking at the public health difficulties facing young people, made even more severe by CoVid 19, in America’s southeastern states. Newkirk says:

So far, about one in 10 deaths in the United States from COVID-19 has occurred in the four-state arc of Louisiana, Mississippi, Alabama, and Georgia, according to data assembled by the COVID Tracking Project, a volunteer collaboration incubated at The Atlantic….The coronavirus is advancing quickly across the American South. And in the American South, significant numbers of younger people are battling health conditions that make coronavirus outbreaks more perilous.

Some context is needed. A new study by the World Health Organization (WHO), endorsed and published by the National Academies of Science, Engineering and Medicine ranks America at or near the worst in just about every mortality rate category you can think of when compared with the other 16 wealthiest countries. U.S. Health in International Perspectives: Shorter Lives, Poorer Health paints a grim picture that should concern us all.

Now, look at the health of people in the deep south, particularly young people, who, according to a new study by the Kaiser Family Foundation, have more comorbidities than young people anywhere else in the country. Those comorbidities put them at much greater risk of becoming seriously ill if they contract CoVid 19.

According to Newkirk:

If you define Oklahoma as part of the South, southern states fill out the entirety of the top 10 states in percentage of population diagnosed with hypertension by a doctor. Southerners are more likely to suffer from chronic diseases than other Americans—even as Americans are more likely to suffer from chronic diseases than citizens of other countries with comparable wealth.

Imagine you have a big barrel full of apples. Inside that barrel is a smaller barrel with apples your farm stand might label “seconds.” Inside that “seconds” barrel is a third and smaller barrel with apples your farm stand wouldn’t ever sell. The third barrel is health in the deep south.

The USNS Comfort

Remember this photo?

That’s the USNS Comfort, the 1,000 bed ship Donald Trump, to great fanfare, sent to New York to help with the serious hospital bed shortage, getting worse every day.

I’m guessing not too many people knew that the Comfort’s orders prohibit treating CoVid 19 patients. As President Trump said when he sent her on her way, “By treating non-infected people remotely on the ship, it will help to halt very strongly the transmission of the virus.” Note the words, “non-infected.”

So far, the Comfort has taken in three of New York’s patients. It’s kind of a Catch 22 thing. The ship can only take patients not infected with CoVid 19, but without sufficient testing, the ship’s clinicians won’t know if anyone actually has the disease, or not. Result: three patients. “If I’m blunt about it, it’s a joke,” said Michael Dowling, the head of Northwell Health, New York’s largest hospital system.

And finally – Getting back to the deep south

The American Association of Medical Colleges is out with its 2019 State Physician Data Workforce Report,

This annual report examines the supply of physicians in the United States. It documents the number of physicians per 100,000 inhabitants of every state. I’m proud, (I think) to report my home state, the Commonwealth of Massachusetts, takes the Gold Medal with 449.5 doctors per 100,000 people. On the other end of the scale, coming in at Number 50, is Mississippi with 191.3. I would love to know what goes on in Mississippi. It seems to be at or near the bottom of anything you can name.

Here are how all the southern states rank:

State                                MDs/100K                       Rank

Mississippi                       191.3                                50

Oklahoma                        206.7                                48

Arkansas                          207.6                                47

Alabama                           217.1                                43

Texas                                224.8                                41

Georgia                            228.7                                39

South Carolina                 229.5                                38

Kentucky                          230.9                                36

Tennessee                        253.1                                29

North Carolina                255.0                                28

Louisiana                          260.3                                27

Florida                              265.2                                23

Given that New York, which is begging for retired clinicians and clinicians from other states to come and help with its CoVid 19 fight, and given that New York, with 375.1 doctors per 100,000 people, ranks Number 3 on the list, just behind Massachusetts and Maryland, how do you think a state like poor Mississippi is going to fair when the full weight of this virus lands on it with a loud thud?

I hope all of you hermits have a safe weekend!

 

 

Andrew Cuomo Is Right: Send Him The Ventilators!

Friday, March 27th, 2020

If the state of New York were a country, it would have the highest rate of CoVid 19 cases per million inhabitants in the world. By far. As of 8:00 AM this morning, 27 March, New York clocked in with 38,987 cases, up more than 8,000 cases, or 27%, from two days ago. With 19.54 million people, New York’s rate of CoVid 19 cases is 1,995 per million inhabitants. The country with the highest rate is Switzerland with 1,387 cases per million inhabitants. But Switzerland only has 8.6 million people.

 

 

The populations of Spain, Italy and France are two to three times that of New York’s; Germany’s four times. So, New York would rank as a relatively small, but still respectably-sized, European country.

Looking at the dire predictions of most experts, Governor Andrew Cuomo believes New York is going to need 30,000 ventilators, and it’s going to need them about two weeks from now.

Donald Trump does not agree. He doesn’t see the need. At his daily… well, what would you call it? It’s certainly not a traditional press briefing. But, whatever you’d call it, yesterday he downplayed the need, and Dr. Deborah Birx, the White House Corona Virus Response Coordinator, whatever that means, sort of backed him up. Sort of. But we’ll get to that in just  a moment.

Last night, talking with Sean Hannity, who may be the sub rosa White House Coordinator, Trump said, “I have a feeling that a lot of the numbers that are being said in some areas are just bigger than they’re going to be. I don’t believe you need 40,000 or 30,000 ventilators. You go into major hospitals sometimes, and they’ll have two ventilators. And now, all of a sudden, they’re saying, ‘Can we order 30,000 ventilators?'”

“I have a feeling.” ” I don’t believe.” Think about that for a minute and ponder the implications.

But back to Dr. Birx, who is skilled at nuance. What did she say about Cuomo’s request for ventilators? She said she was told New York had enough ventilators “to meet current needs.” She said that, while New York City may have a shortage of ventilators at the moment, there are other parts of the state “that have lots of ventilators and other parts of New York state that don’t have any infections right now.”

Unpack what Dr. Birx said and you find she is careful to talk about what is needed right now. Cuomo is talking about what will be needed in two weeks when the proverbial fecal matter has hit the whirring instrument head on.

Right now New York has scrounged up about 15,000 ventilators, half the ventilators Cuomo and his experts say they’ll need in two weeks.

The White House Corona Virus Response Team has a choice here. It can either look at New York with a panoramic view, or continue to pretend they’re glimpsing an arrow as it whizzes past a crack in the door.

If you were making the ventilator decisions, which view would you want?

 

CoVid 19 And The Flu: Some Historical Perspective That Might Surprise You

Thursday, March 26th, 2020

Early in the morning of 4 March 1918, at Fort Riley, Kansas, Private Albert Gitchell reported for sick call at the Fort’s Hospital complaining of sore throat, fever and  a headache. By that noon, more than 100 other Fort Riley soldiers were at the hospital with similar symptoms. This was soon followed by similar outbreaks at other Army posts and prisons around America. Epidemiologists believe this to be the beginning of what came to be known as the Spanish Flu.

That March, 84,000 “Doughboys” shipped out for Europe, to be followed by another 118,000 in April. They brought the highly contagious flu with them. Soon, all of Europe and parts of Asia were infected. In June, Great Britain reported 31,000 cases (As I write this – 26 March – New York is reporting more than 30,000 cases of Covid 19). France and Germany suffered, too. Germany’s Crown Prince Rupprecht wrote on August 3. “Poor provisions, heavy losses, and the deepening influenza have deeply depressed the spirits of men in the III Infantry Division.” Soon, Russia, North Africa, India, China, Japan, the Philippines and even New Zealand would fall victim, as well.

The war ended on 11 November and the soldiers went home, bringing more of the disease with them. A second wave then hit America, much more devastating than the first. It infected 28% of the country’s population including my 5-year old Dad, who survived, thank you very much. It finally petered out at the end of 1919. As today, younger people seemed to combat the disease better than the aged.

From March through November, Americans did not know much about the Flu and its effect on the population. The Central Powers took great pains to censor bad news, trying to keep morale high. The first reports of the Flu came in May from Spain, a neutral country with uncensored media. Hence, it became the Spanish Flu. But when the war ended the ropes came off and the world knew it was in the grips of what would become the worst pandemic in history, rivaled only by the Bubonic Plague, caused by Yersinia Pestis, the black rat, in the mid-14th century. That plague killed more than two million people in England alone, 40% to 50% of the population, and the population would not recover to its former level until the early 1800s.

When Americans finally learned what the Spanish Flu was doing to them what happened?

Well, first of all, there was no vaccine and no curative treatment. Sound familiar? Second, because of not wanting to spread bad news, the government delayed mobilizing fully to combat a different kind of enemy. Sound familiar? When it did, what did it do? As now, with CoVid 19, the burden fell mostly on Governors, Mayors and local health officials. Because the Flu was so widespread, affecting the entire country at once, most states and cities were on their own. Many made tragic mistakes, as many are doing now. Actions in Philadelphia and St. Louis, MO, provide two 1919 examples.

As cases mounted, Philadelphia went forward with a Liberty Loan parade attended by tens of thousands, shoulder to shoulder. The disease exploded exponentially. In just 10 days, over 1,000 Philadelphians were dead, with another 200,000 sick. Only then did the city close saloons and theaters. By March, 1919, over 15,000 Philadelphians had died.

In St. Louis, the mayor ordered schools and movie theatres closed and banned public gatherings. The St. Louis mortality rate was one-eighth that of Philadelphia’s.

On the whole, Americans fought the Spanish Flu the same way we’re fighting CoVid 19 – social distancing, wearing masks and gloves, washing hands and staying at home. They had no cure; neither do we. Eventually, in the 1940s, the first flu vaccine was created. Now, sixty years later, only 40% of Americans take the trouble to get vaccinated yearly for the flu, 30,000 to 40,000 die annually and 200,000 are hospitalized.

Make no mistake. CoVid 19 is not like the flu – of today. But it is very much like the Spanish Flu of 1918 and 1919.

We will have a vaccine to combat CoVid 19. Right now we’re in the middle of a traffic jam of attempts, but it will happen. I only hope for two things. First, that the Corona Virus doesn’t mutate annually, like the flu. Second, that all Americans wake up and get vaccinated for both this virus as soon as they can and, finally, for the flu.

A Warning From One Who Knows

Thursday, March 12th, 2020

CoVid 19 appears to have begun in China. It then made its way around the world, and is now an “official global pandemic.” Last night, Donald Trump, in television primetime, addressed the nation and described what he and his administration are doing and plan to do to mitigate the pandemic’s effects in America. I won’t get into what I thought about his address, except to say that until the Fed intervened two hours ago, the stock market was down 9% and was on pace to have its sixth-worst one-day decline in history. So much for Wall Street’s response.

This morning, Trump, sitting in the Oval Office with Ireland’s Prime Minister, Leo Valadkar, answered questions from the press. He repeatedly made the point that things in America are ever so much better than in Europe, which he seemed to blame for our current pandemic difficulties. We have the “best doctors in the world” and all the resources needed to defeat the oncoming enemy. More than once, he said, “We’ve only had 32 deaths.” He opined in that certitudinous way of his that the virus will go away, maybe in a month or two, and urged everyone to “keep separation.”

I mention this by way of introducing the longest post WorkersCompInsider has ever published, about 2,400 words. And it’s all Dr. Jennifer Christian’s fault.

Jennifer, as many of you may know, is the Moderator of WFDRoundtable, an intelligent, illuminating and educational group chat site for clinicians, academics, workers’ compensation professionals, and anyone else who might be interested in learning what the medical profession, in general, is doing and thinking about sick and injured people. I wrote glowingly about Jennifer and her work in 2014. Might be worth a revisit.

This morning’s Roundtable arrived with Jennifer introducing a Facebook post by Dr. Daniele Macchini, from the Humanitas Gavazzeni hospital in Bergamo, Italy (northeast of Milan). Dr. Macchini is at the center of Italy’s CoVid 19 storm. He is smack dab in the middle of it, and what he’s seen isn’t pretty. He and his colleagues in northern Italy have been through a lot in the last couple of weeks, and what he’s written should be read by every American. it is a picture of what can, and very likely will, happen here, despite our President’s protestations to the contrary.

This is Dr. Macchini’s story. It’s been Google-Translated from Italian.

In one of the constant emails that I receive from my health department more than daily now these days, there was also a paragraph entitled “being sociably responsible”, which made some recommendations that I support. After thinking for a long time if and what to write about what is happening to us, I felt that silence was not at all responsible. I will therefore try to convey to people “not involved in the work” and more distant from our reality, what we are experiencing in Bergamo during these pandemic days from Covid-19.

I understand the need not to panic. I also understand the economic damage and I am also worried about that. After the epidemic, the tragedy will start again. However, apart from the fact that we are literally also devastating our National Health Service from an economic point of view, I allow myself to raise the importance of the health damage that is likely throughout the country and I find it nothing short of “chilling” for example that a red zone already requested by the region has not yet been established for the municipalities of Alzano Lombardo and Nembro (I would like to clarify that this is pure personal opinion).

I myself looked with some amazement at the reorganizations of the entire hospital in the previous week, when our current enemy was still in the shadows: the wards slowly “emptied”, the elective activities interrupted, the intensive therapies freed to create as many beds as possible. Containers arriving in front of the emergency room to create diversified routes and avoid any infections. All this rapid transformation brought into the corridors of the hospital an atmosphere of surreal silence and emptiness that we still did not understand, waiting for a war that was yet to begin and that many (including me) were not so sure would never come with such ferocity . (All this was done in silence and without publicity.)

I still remember my night watch a week ago that passed anxiously as I waited for a call from the microbiology unit. I was waiting for the outcome of a swab on the first suspect patient in our hospital, thinking about what consequences it would have for us and the clinic. If I think about it, my agitation for one possible case seems almost ridiculous and unjustified, now that I have seen what is happening.

Well, the situation is now nothing short of dramatic. No other words come to mind. The war has literally exploded and the battles are uninterrupted day and night. One after the other the unfortunate poor people come to the emergency room. What they have is nothing like the complications of a flu. Let’s stop saying it’s a bad flu. In these 2 years I have learned that the people of Bergamo do not come to the emergency room without cause. They did well this time too. They followed all the indications given: a week or ten days at home with a fever without going out and risking contagion, but now they can’t take it anymore. They can get enough breath, they need oxygen.

Drug therapies for this virus are few. The course mainly depends on our organism. We can only support it when it can’t take it anymore. It is mainly hoped that our body will eradicate the virus on its own, let’s face it. Antiviral therapies are experimental on this virus and we learn its behavior day after day. Staying at home until the symptoms worsen does not change the prognosis of the disease.

Now, however, that need for beds in all its drama has arrived. One after another, the departments that had been emptied are filling up at an impressive rate. The display boards with the names of the sick, of different colors depending on the operating unit they belong to, are now all red and instead of the surgical operation there is the diagnosis, which is always the same cursed: bilateral interstitial pneumonia.

Now, tell me which flu virus causes such a rapid tragedy. Because that’s the difference (now I’m going down a bit in the technical field): in classical flu, apart from infecting much less of the population over several months, cases can be complicated less frequently, only when the VIRUS destroying the protective barriers of the our respiratory tract allowing BACTERIA normally resident in the upper tract to invade the bronchi and lungs, causing more serious cases. Covid 19 is mild in many young people, but in many elderly people (and not only) it causes a real Sudden Acute Respiratory Syndrome because it arrives directly in the alveoli of the lungs and infects them making them unable to perform their function.

Sorry, but to me as a doctor it shouldn’t reassure you that the most serious are mainly elderly people with other pathologies. The elderly population is the most represented in our country and it is difficult to find someone who, above 65 years of age, does not take at least the tablet for pressure or diabetes. I also assure you that when you see young people who end up in intubated intensive care, pronated or worse in ECMO (a machine for the worst cases, which extracts the blood, re-oxygenates it and returns it to the body, waiting for the organism, hopefully, heal its lungs), any comfort you might take from being young passes then and there.

And while there are still people on social networks who pride themselves on not being afraid by ignoring the indications, protesting that their normal lifestyle habits are “temporarily” in crisis, the epidemiological disaster is taking place. And there are no more surgeons, urologists, orthopedists. We are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us. The cases multiply, we arrive at the rate of 15-20 hospitalizations a day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the emergency room is collapsing.

Emergency provisions are issued: help is needed in the emergency room. A quick meeting to learn how the first aid management software works and a few minutes later they are already downstairs, next to the warriors on the war front. The screen of the PC with the reasons for the access is always the same: fever and respiratory difficulty, fever and cough, respiratory insufficiency etc … Exams, radiology always with the same sentence: bilateral interstitial pneumonia, bilateral interstitial pneumonia, bilateral interstitial pneumonia. All to be hospitalized. Someone already to intubate and go to intensive care. For others it is too late …

Intensive care becomes saturated, and where intensive care ends, more are created. Each ventilator becomes like gold: those of the operating rooms that have now suspended their non-urgent activity become places for intensive care that did not exist before. I found it incredible, or at least I can speak for Humanitas Gavazzeni (where I work) how it was possible to put in place in such a short time a deployment and a reorganization of resources so finely designed to prepare for a disaster of this magnitude. And every reorganization of beds, departments, staff, work shifts and tasks is constantly reviewed day after day to try to give everything and even more.

Those wards that previously looked like ghosts are now saturated, ready to try to give their best for the sick, but exhausted. The staff is exhausted. I saw fatigue on faces that didn’t know what fatigue was despite the already grueling workloads they had. I have seen people still stop beyond the times they used to stop already, for overtime that was now habitual. I saw solidarity from all of us, who never failed to go to our internist colleagues to ask “what can I do for you now?” or “leave alone that shelter that I think of it.” Doctors who move beds and transfer patients, who administer therapies instead of nurses. Nurses with tears in their eyes because we are unable to save everyone and the vital signs of several patients at the same time reveal an already marked destiny.

There are no more shifts, schedules. Social life is suspended for us. I have been separated for a few months, and I assure you that I have always done everything possible to constantly see my son even on the days of taking the night off, without sleeping and postponing sleep until when I am without him, but for almost 2 weeks I have voluntarily avoided my son nor my family members for fear of infecting them and in turn infecting an elderly grandmother or relatives with other health problems. I’m happy with some photos of my son that I regard between tears and a few video calls.

So be patient too, you can’t go to the theater, museums or gym. Try to have mercy on that myriad of older people you could exterminate. It is not your fault, I know, but of those who put it in your head that you are exaggerating and even this testimony may seem just an exaggeration for those who are far from the epidemic, but please, listen to us, try to leave the house only to indispensable things. Do not go en masse to stock up in supermarkets: it is the worst thing because you concentrate and the risk of contacts with infected people who do not know they are higher. You can go there as you usually do. Maybe if you have a normal mask (even those that are used to do certain manual work) put it on. Don’t look for disease masks. Those should serve us and we are beginning to struggle to find them. By now we have had to optimize their use only in certain circumstances, as the WHO recently suggested in view of their almost ubiquitous impoverishment.

Oh yes, thanks to the shortage of certain devices, I and many other colleagues are certainly exposed despite all the means of protection we have. Some of us have already become infected despite the protocols. Some infected colleagues in turn have infected family members and some of their family members already struggle between life and death. We are where your fears could make you stay away. Try to make sure you stay away. Tell your elderly or other family members to stay indoors. Bring him the groceries please.

We have no alternative. It’s our job. In fact, what I do these days is not really the job I’m used to, but I do it anyway and I will like it as long as it responds to the same principles: try to make some sick people feel better and heal, or even just alleviate the suffering and the pain to those who unfortunately cannot heal.

On the other hand, I don’t spend a lot of words about the people who call us heroes these days and who until yesterday were ready to insult and report us. Both will return to insult and report as soon as everything is over. People forget everything quickly. And we’re not even heroes these days. It’s our job. We risked something bad every day before: when we put our hands in a belly full of blood of someone we don’t even know if he has HIV or hepatitis C; when we do it even though we know it has HIV or hepatitis C; when we sting with the one with HIV and take the drugs that make us vomit from morning to night for a month. When we open with the usual anguish the results of the tests at the various checks after an accidental puncture hoping not to be infected. We simply earn our living with something that gives us emotions. It doesn’t matter if they are beautiful or ugly, just take them home.

In the end we only try to make ourselves useful for everyone. Now try to do it too though: with our actions we influence the life and death of a few dozen people. You with yours, many more. Please share and share the message. We must spread the word to prevent what is happening here in Italy.

What Price Life?

Thursday, November 29th, 2018

Part One

“Insulin is my gift to mankind” – Frederick Banting

A Quick Quiz

Question 1: Name a chronic disease requiring medication, which, if not taken every day, guarantees death within two weeks.
Answer: Type 1 Diabetes.

Question 2: Name the medication.
Answer: Insulin.

Question 3: What is the monthly cost of insulin for a Type 1 diabetic?
Answer: As we shall see, that depends.

Question 4: If Type 1 diabetics cannot afford the cost of insulin, without which they will surely die, what should they do?
Answer: This is happening at this moment, and people are dying.  In these two blog posts we’ll examine why and what can be done about it. But we need to first posit some truths about diabetes, and then describe how, in 1922, Canadian doctor Frederick Banting made the ground-breaking discovery that allowed Type 1 diabetics, for the first time in history, to live.

Ten Fast Facts

  1. Insulin is a hormone made by the pancreas that allows the body to use sugar (glucose) from carbohydrates in the food we eat for energy or to store glucose for future use. Insulin helps keeps blood sugar levels from getting too high (hyperglycemia) or too low (hypoglycemia). Type 1 diabetics, T1Ds, can no longer produce insulin. They have none of it. Although older adults can also contract Type 1 diabetes, it usually strikes children and young adults. Without insulin, whether old or young, they die.
  2. There are about 1.3 million T1Ds in the U.S. They comprise one half of one percent of the population. Currently, there is no cure for any of them. Without insulin, they will die.
  3. There are about 29 million Type 2 diabetics. T2Ds still make some insulin. In most, lifestyle changes will improve their health, sometimes to the point where they will no longer require insulin or any other medical prescriptions. Some will become insulin-dependent, and without it, they face life-changing complications.
  4. Diabetic Retinopathy is the leading cause of blindness.
  5. Diabetes is the leading cause of non-traumatic amputation.
  6. Diabetes is a leading cause of heart attack and stroke.
  7. Diabetes is the leading cause of kidney failure.
  8. Complications from diabetes sometimes cause workplace injuries and often exacerbate the severity and length of recovery.
  9. In 2017, the nation’s total direct medical costs due to diabetes were $237 billion. Average medical expenses for diabetics were 2.3 times higher than for non-diabetics. The extent to which diabetes added to workers’ compensation medical costs is unknown.
  10. Based on information found on death certificates, diabetes was the 7th leading cause of death in the United States in 2015, with 79,535 death certificates listing it as the underlying cause of death, and 252,806 listing diabetes as an underlying or contributing cause of death. However, diabetes is underreported as a cause of death; studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on the death certificate and only 10% to 15% had it listed as the underlying cause of death. An example of best practice would be, “Death caused by infection contracted from hemodialysis due to kidney failure, a complication of the patient’s diabetes.”

Banting and Insulin

Image result for photo of frederick banting

Frederick Banting is perhaps Canada’s greatest hero. Born in 1891, he graduated medical school with a surgical degree in 1915 and found himself in a French trench by the end of 1917. In December of that year, he was wounded during the Battle of Cambrai, the first great tank battle in history. He remained on the battlefield for 16 hours tending to other wounded soldiers until he had to be ordered to the rear to have his own wounds treated. For this action he won the British Military Cross, akin to America’s Silver Star. After returning to Canada, he continued his studies and, in 1920, secured a part time teaching post at Western Ontario University. While there, he began studying insulin Why? Serendipity. Someone had asked him to give a talk on the workings of the pancreas.

Banting became interested – and then obsessed – with trying to come up with a way to get insulin to people who couldn’t make any of their own. In November 1921, he hit on the idea of extracting insulin from fetal pancreases of cows and pigs. He discussed the approach with J. R. R. MacLeod, Professor of Physiology at the University of Toronto. MacLeod thought Banting’s idea was doomed to failure, but he allowed him to use his lab facilities while he was on a golfing holiday in Scotland. He also loaned him two assistants, Dr. Charles Best and biochemist James Collip. Collip devised a method to purify the insulin Banting and Best obtained from the fetal pancreases.

To MacLeod’s surprise, Banting’s procedure worked, and in 1922 Banting and Best successfully treated the daughter of US Secretary of State Charles Evans Hughes.

In 1923, one year later, Banting, at the age of 32, won the Nobel Prize, which, to his disgust, he had to share with MacLeod. To this day, Frederick Banting is the youngest person ever to win the Prize in Physiology or Medicine.

His discovery could have made Banting mind-numbingly rich, but he would have none of that. Along with Best and Collip, Banting patented his method and then the three of them sold the patent to the University of Toronto for the princely sum of $3.00. When asked why he didn’t cash in on his discovery, Banting said, “Insulin is my gift to mankind.” With Banting’s blessing, the University licensed insulin’s manufacturing to drug companies, royalty free. If drug companies didn’t have to pay royalties, Banting thought they would keep the price of insulin low.

And they did. For decades.

But patents expire, and capitalism being what it is, people get greedy, and greed is why we have no generic, low-cost insulin today and why, over the past 20 years, insulin prices have risen anywhere from 800% to 1,157%, depending on the variety and brand. It’s why, lacking health insurance, some Type 1 diabetics have recently been driven to ration their precious insulin. Some of them have died.

More about all that in Part Two.

 

 

 

Bulletin: Dog Catches Bus! Now What?

Tuesday, June 12th, 2018

We’re goin’ right straight back to 2010
To start the health care war all over again!

It took time, but the GOP has finally learned a thing or two about fighting the Affordable Care Act, or, as they insist on calling it: Obamacare. You will recall that in 2017, after achieving control of all three branches of government, the party of Abraham Lincoln launched, in another Ground Hog Day moment, its biggest ever attack on the ACA, only to see its troops repulsed and annihilated once again by the turned down thumb of a war hero.

And then, after so many defeats there was a “light dawning over Marblehead” moment that would have made Prince Talleyrand proud.  In what the army calls a “triple flank,” republicans:

  1. In their humongously big 2017 tax cut law, zeroed out the penalty for not having health insurance;
  2. In February, 2018, got 20 states to sue the federal government contending that repeal of the penalty obviates the individual mandate making the entirety of the ACA unconstitutional.
  3. In May, 2018, somehow convinced the Justice Department not to defend the government in the suit.

Wow! A trifecta!

If the 20 states prevail, collateral damage abounds. First and foremost, the ACA’s provision that insurers not discriminate against people with pre-existing conditions. There are about 133 million Americans, under the age of 65, who fall into that health care Punji Pit. Prior to the ACA these family members, friends or neighbors of ours could be either denied coverage relating to their conditions, or charged exorbitant premiums. Beginning in 2014, the ACA forbade that. If the states win their suit, that meaty provision of the law, which a Kaiser tracking poll shows 70% of the population supports, gets torn up into little pieces and fed to the crows.

You might ask, “What do insurance companies think about all this?” Well, they do not like it one bit. America’s Health Insurance Plans, the trade association for health insurance companies, supports the pre-existing condition protections under the ACA. “Removing those provisions will result in renewed uncertainty in the individual market, create a patchwork of requirements in the states, cause rates to go even higher for older Americans and sicker patients, and make it challenging to introduce products and rates for 2019,” AHIP said in a statement.

So, here’s the question: If the 20 states actually win their suit, what happens then? Among many groups, the 1.25 million Americans with Type 1 diabetes who need to inject costly insulin every day to stay alive are waiting for an answer.

It’s The Zip Code, Stupid! Update

Thursday, May 10th, 2018

At the end of February 2018, we wrote about a May 2017 study in JAMA Internal Medicine that concluded that where one lives is a bigger factor in health care outcomes than actual health care. This from our February post:

Geography is the biggest X-Factor in today’s American Hellzapoppin version of health care. The study analyzed every US county using data from deidentified death records from the National Center for Health Statistics (NCHS), and population counts from the US Census Bureau, NCHS, and the Human Mortality Databas and found striking differences in life expectancy. The gap between counties from lowest to highest life expectancy at birth was 20.1 years.

And, surpirse, surprise, it turns out if you live in a wealthy county with excellent access to high level health care, like Summit County, Colorado (life expectancy: 86.83), you’re likely to live about 15 years longer than if you live, say, in Humphries County, Mississippi, where life expectancy at birth is 71.9 years.  So, yes, Zip Code matters.

The concept of  zip code influence seems to be gaining traction. Today, from AIS Health Daily, we learn  a number of Blues Plans are planning on targeting the “where you live” problem with innovative strategies. Here is the AIS Daily release:

Blues Plans Work to Combat “ZIP Code Effect”
The Blue Cross and Blue Shield Association (BCBSA) recently launched the Blue Cross Blue Shield Institute, a subsidiary of BCBSA created to address social and environmental issues, as evidence mounts that health outcomes may be affected as much or more by social determinants of health as they are by actual medical care.
The Blue Cross Blue Shield Institute says it will address what it calls the “ZIP code effect,” which encompasses transportation, pharmacy, nutrition and fitness deserts in specific neighborhoods. It is partnering with Lyft, Inc., CVS Health Corp. and Walgreens Boots Alliance to address transportation and pharmacy deserts. The institute says it plans to deal with fitness and nutrition deserts in 2019.
Meanwhile, Highmark Inc. will launch a transportation initiative this summer to provide rides for members with chronic health conditions who live in a transportation desert. The service will begin in Pittsburgh as a pilot.
On April 17, Highmark’s Allegheny Health Network opened its Health Food Center, which acts as a “food pharmacy” where patients who lack access to food can receive nutritious food items, education on disease-specific diets and additional services for other social challenges they may face.
Other Blues plans also are addressing social determinants of health. For instance, Blue Cross and Blue Shield of North Carolina intends to invest part of its savings from the Tax Cuts and Jobs Act of 2017 into community health programs.
At Independence Blue Cross, the Independence Blue Cross Foundation’s Blue Safety Net Program offers “mobilized services” to medically underserved communities. The IBC Foundation sponsors the Philadelphia Eagles Youth Partnership’s Eagles Eye Mobile to conduct free vision screenings and eye exams and provide prescription glasses to under-insured and uninsured children.
We salute the Blues for recognizing the problem and trying to do something productive about it.
Final thought: If you do not subscribe to AIS Health Daily, you should.

Medical Care Experts: Where Would We Be Without Them?

Monday, August 7th, 2017

If you’ve been following the blog-o-sphere and the LinkedIn-o-sphere, you know that the space is crowded. Lots of workers’ comp practitioners have glommed on to the idea that the way to get ahead is to write and post frequently. Connect with more than 500 others in the profession. Write something, anything, put your name on it and throw it up against the wall to see if anything sticks. Kind of the way Garrison Keillor used to say he changed socks on a book tour.

Every once in a while, something helpful and interesting appears and gains a bit of temporary caché for itself and for its author. Mostly, the topics center on the persistent rise in medical costs and, even more often, on the insidious and often criminal use of opioids, which a regrettable number of alleged doctors, having checked their Hippocratic Oath at the door, are prescribing at a hell-bent-for-leather rate at a hell-bent-for-leather profit. The poor, unfortunate souls for whom these scripts are written are nothing more than high-cost collateral damage.

Consequently, efforts to control workers’ compensation costs are now almost entirely dedicated to reining in costs associated with medical care with a huge emphasis on prescription drugs.

And why not? Injury frequency continues its 13 year, asymptotic approach to zero. While the same can’t be said for injury severity, these are, nonetheless, heady times for insurers. Kind of hard not to make money when the combined ratio is in the 90s.

Regardless of how good things are getting in workers’ comp world, the workplace is still the best place to control and manage the work injuries and costs that are bound to occur despite frequency’s decline and the rise of the robots. But that requires educated employers who understand that they, not the vendors to whom they outsource payment responsibilities, are the hub of the workers’ comp wheel.  Who approach workers’ compensation in a Management 101 kind of way understanding that a systemic, accountable process will reduce costs to a minimum and bolster profits as well as employee morale and productivity.

This means training supervisors in the proper response to work injuries, keeping close communication with injured workers, creating good relationships with treating physicians, bringing injured workers back to work as soon as possible under medical supervision, seeing that injured workers receive full pay while on modified duty, and measuring success every month just as one measures success in every other business enterprise.

These, and other program components, give enlightened employers a distinctive competitive advantage, and the results will speak for themselves.

But not all employers are enlightened; many have lost their way. Why?

Well, could it be we took a system we had made relatively simple for employers to manage (and let’s not forget that it is employers who ultimately pay the bills) and made it progressively more complicated with progressively more vested interests?

Many middle market employers, realizing they have no hope of navigating the haunted house maze medical care has become, have relinquished control to a myriad of vendors, the “experts.” Climbing this Tower of Babel is beyond them.

The question is: Can we do anything about this? Should we? Or, has this ship long ago sailed?

Reactions To “Pharma’s Nine Words”

Monday, May 15th, 2017

We received a lot of thoughtful feedback to last week’s post on drug company Direct To Consumer (DTC) television advertising. I thought I’d share a couple that are representative of the whole.

This from a doctor in Florida:

You have acutely illustrated the challenge that allopathic physicians now battle with every day. In short, big Pharma has found a way to circumnavigate the drug salesperson and physician and go directly to the end consumer
Every physician feels significant pressure to satisfy their patients even when the request for certain pharmaceuticals is unreasonable; if the patient walks out of your office empty-handed chances are they won’t come back, so at the very least most patients have some prescription in hand upon their exit.

And this from a C-Suite Chief of Marketing:

I must confess upfront that I was one of those “DTC advertisers” in the early 2000s, having worked with Eli Lilly, Boehringer Ingelheim and Pfizer to name a few former clients.

Over the years I’ve read conflicting studies on DTC’s effectiveness and impact.  This said, there is typically a relationship between the largest category spender and market share.

You may also be interested in a dated survey from the FDA on the subject.  While there are definitely some “pro’s” associated with these efforts, including but not limited to patient empowerment (more prepared for doctor’s appointment, asking thoughtful questions, generally being more involved in one’s health, and better conversations about one’s condition and possible treatments). But there are also some “con’s,” including but not limited to:  overpromises/over statements of a drug’s potential benefits (and a corresponding downplay of possible side effects); pressure on physician’s part to prescribe a patient-requested drug, among others.  (But let’s not forget that there were physicians who were also in pharma’s pockets long before DTC, prescribing certain drugs based on lucrative relationships with companies.  Certainly not all of them… but unfortunately there were – and likely still are – some “bad apples.”)

It will be interesting to see how this debate evolves as baby boomers age.  Let’s hope that the patient is the ultimate winner here!

We can all agree with that last bit about hoping the “patient is the ultimate winner.”

We welcome responsible, thoughtful comments from our readers.

 

 

Wonks opine on Republican healthcare plan & more

Thursday, March 9th, 2017

Check out the freshly posted “May You Live in Interesting Times” Edition of Health Wonk Review posted by Peggy Salvatore at Health System Ed Blog. If your head hurts from trying to analyze the new plan, let the wonks lighten your load – some pretty smart people have weighed in.

Of course, while Obamacare past, present and future is the 800 pound gorilla in the room. that’s not the only issue discussed in this weighty issue. Other topics include a tribute to a health care advocate pioneer, a look at our new Secretary of Labor, posts on cancer care, clinical outcome technology, cyber security and medical marijuana.